Supporting midwifery is the answer to the wicked problems in maternity care
Authors: Hannah G Dahlen, Daniela Drandic, Neel Shah, Franka Cadee, Address Malata
Journal: The Lancet Global Health (2022)

The film Don't Look Up, examines what it will take to get world leaders and the public to be proactive about a comet that is on a collision course with earth. We argue that the same attitude of self-interested denialism is stopping crucial action being taken when it comes to supporting midwifery models of care to address the current problems in maternity care. Although life-saving when indicated, medical interventions in childbirth can be harmful when overused.1Shaw D Guise J-M Shah N et al.Drivers of maternity care in high-income countries: can health systems support woman-centred care?.Lancet. 2016; 388: 2282-2295Summary Full Text Full Text PDF PubMed Scopus (116) Google Scholar A challenge in striking the right balance is that the bar for benefit when it comes to birth outcomes has been set at immediate survival. This approach overlooks clinical complications, such as placenta praevia or accreta associated with caesarean, and fails to value the personal autonomy of women and communities. In global settings, caesarean section rates, which are often used as a proxy to understand the safety of a maternity system, have recently come under scrutiny. Inquiries into adverse outcomes in the Shrewsbury and Telford Hospital National Health Service Trust in the UK has led to sensational media reporting and concerns about the dangers of setting caesarean section targets.2Hicking S NHS England scrap caesarean section targets. National Health Executive, 2022https://www.nationalhealthexecutive.com/articles/nhs-england-scrap-caesarean-targetsDate accessed: May 19, 2022Google Scholar This reporting has led to a focus on individual decision makers rather than faulty systems. We know a bad system will beat the best health-care provider every time The centrality of midwives in supporting the physiological process of giving birth is at the core of this debate. Midwives have been singled out for blame when it comes to poor outcomes, with little consideration given to the fragmented models of care they work in, where they do not always have professional autonomy and respectful collaboration. This attitude creates an environment of professional and philosophical conflict that does not put women's optimal care and needs at the centre. Relational models of care such as continuity of midwifery care, which are supported by high-level evidence as being cost effective and leading to optimal outcomes,3Sandall J Soltani H Gates S Shennan A Devane D Midwife-led continuity models versus othermodels of care for childbearing women during pregnancy, birth and early parenting.Cochrane Database Syst Rev. 2016; 4CD004667PubMed Google Scholar are ignored. Such models have the potential to save 4·3 million lives per year,4Nove A Friberg IK de Bernis L et al.Potential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: a Lives Saved Tool modelling study.Lancet Glob Health. 2021; 9: e24-e32Summary Full Text Full Text PDF PubMed Scopus (47) Google Scholar but realising this opportunity requires a deeper understanding of why they are not reaching scale. The way we treat women during pregnancy, childbirth, and postpartum, and the institutional options of care we provide them within health systems, directly reflect the way we value women in our societies. In too many settings we are ignoring the benefits of midwifery models of care, degrading the status of midwives, and removing financing from midwifery services and education, under the guise of safety that ignores physiology and women's chances for optimal mental and physical health. There is a shortage of approximately a third of the midwives we need globally, which is crucial considering that midwives who are educated and regulated to international standards of care can provide 87% of essential maternity care needs and would prevent 67% of maternal deaths, 64% of newborn deaths, and 65% of stillbirths.4Nove A Friberg IK de Bernis L et al.Potential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: a Lives Saved Tool modelling study.Lancet Glob Health. 2021; 9: e24-e32Summary Full Text Full Text PDF PubMed Scopus (47) Google Scholar Midwifery provides a 16 times return on investment.3Sandall J Soltani H Gates S Shennan A Devane D Midwife-led continuity models versus othermodels of care for childbearing women during pregnancy, birth and early parenting.Cochrane Database Syst Rev. 2016; 4CD004667PubMed Google Scholar, 5UNFPAICMWHOThe state of the world's midwifery 2014: a universal pathway. A women's right to health. United Nations Population Fund, Geneva, Switzerland2014Google Scholar Evidence is mounting on how midwives improve maternity care globally; yet, midwives are leaving the profession—burned out, disillusioned, and under valued.6UNFPAICMWHOThe State of the World's Midwifery 2021. United Nations Population Fund, Geneva, Switzerland2021Google Scholar The latest sensationalised media reporting in the UK has demoralised midwives even more, with global impacts. As a predominantly female profession, midwives continue to be marginalised, overworked, poorly paid, and do not have decision making authority in many countries.6UNFPAICMWHOThe State of the World's Midwifery 2021. United Nations Population Fund, Geneva, Switzerland2021Google Scholar The aim of intervening in the physiological processes of pregnancy and birth is to improve outcomes and safety for women and babies.7WHOWHO recommendations: intrapartum care for a positive childbirth experience. World Health Organization, Geneva, Switzerland2018Google Scholar Commonly used birth interventions such as caesarean sections and induction, which were previously used to treat obvious complications, are used more commonly for women that are unlikely to benefit from them, and can even cause harm to healthy women.8Sandall J Tribe RM Avery L et al.Short-term and long-term effects of caesarean section on the health of women and children.Lancet. 2018; 392: 1349-1357Summary Full Text Full Text PDF PubMed Scopus (374) Google Scholar, 9Moynihan R Doust J Henry D Preventing overdiagnosis: how to stop harming the healthy.BMJ. 2012; 344e3502Crossref Scopus (444) Google Scholar These harms contribute to gender, racial, and geographical inequities, and there is growing concern regarding generational inequities. Less concern is afforded to women suffering from birth trauma, which is higher following intervention in birth, especially when women feel poorly informed and coerced into this.10Vedam S Stoll K Taiwo TK et al.The giving voice to mothers study: inequity and mistreatment during pregnancy and childbirth in the United States.BMC Reprod Health. 2019; 16: 77Crossref PubMed Scopus (183) Google Scholar Although high-income countries (HICs) often drive the dominant discourse when it comes to maternity care, in some low-income and middle-income countries (LMICs) women cannot access a safe caesarean section even when it is needed, demonstrating significant inequalities in maternal care.11Miller S Abalos E Chamillard M et al.Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide.Lancet. 2016; 388: 2176-2192Summary Full Text Full Text PDF PubMed Scopus (516) Google Scholar Caesarean section rates have escalated in LMICs without adequate training or access to additional skills such as anaesthetics, leading to deadly outcomes; and maternal mortality rates are up to 100 times higher in LMICs than HICs.12Betrán AP Ye J Moller AB Zhang J Gülmezoglu AM Torloni MR The increasing trend in caesarean section rates: Global, regional and national estimates: 1990–2014.PLoS One. 2016; 11e0148343Crossref Scopus (1012) Google Scholar There is increased economic hardship for communities and stretched health systems, and distrust of hospital care and health-care providers.8Sandall J Tribe RM Avery L et al.Short-term and long-term effects of caesarean section on the health of women and children.Lancet. 2018; 392: 1349-1357Summary Full Text Full Text PDF PubMed Scopus (374) Google Scholar Women who become pregnant after caesarean section are at a higher risk of subsequent surgery, with inadequate attention given to additive morbidity over their reproductive life course. The use of technology and interventions in childbirth scale up quickly and are difficult to de-implement, even when there is evidence of harm. Fiscal accountability and resource-intense care that contributes to the health-care carbon footprint (10% of the US total) should be key considerations. To meet the 2030 Sustainable Development Goals and prevent an unfolding disaster, we call for urgent action and a united voice on the four main groups of action in the Midwifery 2030 Pathway (panel).13ten Hoope-Bender P Lopes ST Nove A et al.Midwifery 2030: a woman's pathway to health. What does this mean?.Midwifery. 2016; 32: 1-6Summary Full Text Full Text PDF PubMed Scopus (23) Google ScholarPanelMidwifery 2030: a pathway to healthGovernance and health systems •All women of reproductive age, including adolescents, have access to midwifery care when needed•Governments provide and are held accountable for a supportive policy environment•Governments and health systems provide and are held accountable for a fully enabled work environment where midwifery professionals can provide the best quality care in accordance with their full scope of practice and competencies•Midwifery care is prioritised in national health budgets; all women are given universal financial protection in accordance with the universal access to health visionHealth services •Midwifery care is delivered in collaborative practice involving health-care professionals, associates, and lay health workers, which increases the quality of care and the health gains for women and their families•First-level midwifery care close to the woman and her family with seamless transfer to next-level care if needed is in line with the vision of universal health care that is centred at primary level•All health-care professionals provide and are enabled to deliver respectful quality careHealth workers •The midwifery workforce is supported through quality education, regulation, and effective human and other resource management. Education, regulation, and association are considered the three pillars for an enabled and competent midwifery workforce•Professional associations provide leadership to their members to facilitate quality care provisionInformation •Data collection and analysis are embedded into service delivery and development, by routine data collection and registers that are integrated into regional and national health information systems Governance and health systems •All women of reproductive age, including adolescents, have access to midwifery care when needed•Governments provide and are held accountable for a supportive policy environment•Governments and health systems provide and are held accountable for a fully enabled work environment where midwifery professionals can provide the best quality care in accordance with their full scope of practice and competencies•Midwifery care is prioritised in national health budgets; all women are given universal financial protection in accordance with the universal access to health vision Health services •Midwifery care is delivered in collaborative practice involving health-care professionals, associates, and lay health workers, which increases the quality of care and the health gains for women and their families•First-level midwifery care close to the woman and her family with seamless transfer to next-level care if needed is in line with the vision of universal health care that is centred at primary level•All health-care professionals provide and are enabled to deliver respectful quality care Health workers •The midwifery workforce is supported through quality education, regulation, and effective human and other resource management. Education, regulation, and association are considered the three pillars for an enabled and competent midwifery workforce•Professional associations provide leadership to their members to facilitate quality care provision Information •Data collection and analysis are embedded into service delivery and development, by routine data collection and registers that are integrated into regional and national health information systems Safe care means respectful care that is informed by women and provided by a known midwife who provides a relational model of care within a responsive, collaborative, and evidence-based health system. Sustainable care happens in health systems that prioritise finite health-care resources, are cognisant of their environmental impact and responsibilities, and value and protect their workforce. Midwifery care uses more efficient resources and provides better outcomes and value than other models of maternity care.5UNFPAICMWHOThe state of the world's midwifery 2014: a universal pathway. A women's right to health. United Nations Population Fund, Geneva, Switzerland2014Google Scholar In light of growing global crises and misinformation, now is the time to provide a united and diligent response to humanise and de-escalate the overmedicalisation of maternity services. What will it take to get the world to "look up" when it comes to maternity care? We declare no competing interests. Be as you wish to seem: tragedy, triumphalism, and toxicity in maternity servicesWomen aspire to positive birth experiences and expect a live baby in their arms at the end of this process. In their Comment, Hannah Dahlen and colleagues (July, 2022)1 proclaim that women are so poorly served by current models that the aspirations of birthing women have been "set at immediate survival". The 2022 Ockenden report highlighted that a fixation on reducing the number of caesarean sections meant that survival was more than what many women could expect. Over 200 babies and nine women served by maternity services at the Shrewsbury and Telford Hospital National Health System Trust in the UK died from systemic failures that included insufficient staff training, inadequate monitoring, poor working cultures, and an organisational drive to reduce the number of caesarean births underpinned by a truculent ideology of normal birth. Full-Text PDF Open AccessBe as you wish to seem: tragedy, triumphalism, and toxicity in maternity services – Authors' replyWe thank Elizabeth Sutton and colleagues for their letter emphasising that survival is the fundamental expectation of women during childbirth. Our argument is that, in designing a better system, we should aim higher. Women clearly also have goals other than emerging from childbirth unscathed. Ideally, care should be supportive, affirming, and empowering. We do not contest the Ockenden report, which clearly shows a betrayal of safety among the UK National Health Service Trust involved. We believe that the public discourse, including media reporting, would benefit from a more holistic and global perspective rather than castigating the midwifery profession, especially considering the global shortage of midwives and the potential impact this has on the lives of women and babies. Full-Text PDF Open Access